Basic Information
| Provider Information | |||||||||
| NPI: | 1548686868 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3387 S US HIGHWAY 41 STE A | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478024188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122325532 | ||||||||
| FaxNumber: | 8122322574 | ||||||||
| Practice Location | |||||||||
| Address1: | 4001 WABASH AVE STE C | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478031647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128770506 | ||||||||
| FaxNumber: | 8128771844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2014 | ||||||||
| LastUpdateDate: | 09/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 28176662A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 201216600 | 05 | IN | MEDICAID | 000000863791 | 01 | IN | ANTHEM | OTHER |